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<div class="control-group ticket_section"> <label class=" required control-label cf_identified_first_770455-label " for="helpdesk_ticket_cf_identified_first_770455">(Who Identified the issue) First Name </label> <div class="controls "> <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_identified_first_770455" name="helpdesk_ticket[custom_field][cf_identified_first_770455]" size="30" type="text" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_identified_last_770455-label " for="helpdesk_ticket_cf_identified_last_770455">(Who Identified the issue) Last Name</label> <div class="controls "> <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_identified_last_770455" name="helpdesk_ticket[custom_field][cf_identified_last_770455]" size="30" type="text" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_event_date_770455-label " for="helpdesk_ticket_cf_event_date_770455">Date of Occurrence</label> <div class="controls support-date-field "> <input class=" required date section_field datepicker_popover" data-date-format="d M, yy" data-show-image="true" id="helpdesk_ticket_custom_field_cf_event_date_770455" name="helpdesk_ticket[custom_field][cf_event_date_770455]" readonly="readonly" type="text" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_description_770455-label " for="helpdesk_ticket_cf_description_770455">Description of the incident or issue</label> <div class="controls "> <textarea class=" required paragraph section_field span12" cols="40" id="helpdesk_ticket_custom_field_cf_description_770455" name="helpdesk_ticket[custom_field][cf_description_770455]" rows="6"> </textarea> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_injury_770455-label " for="helpdesk_ticket_cf_injury_770455">Did a serious injury or safety concern occur?</label> <div class="controls "> <select class=" required dropdown_blank section_field dynamic_sections" id="helpdesk_ticket_custom_field_cf_injury_770455" name="helpdesk_ticket[custom_field][cf_injury_770455]"><option value="">...</option> <option value="No" data-id="35000900360">No</option> <option value="Yes" data-id="35000900361">Yes</option></select> </div> </div> <div class="control-group ticket_section"> <div class="controls"> <label class="checkbox "> <input name="helpdesk_ticket[custom_field][cf_clinical_investigation_device_770455]" type="hidden" value="0" /><input class=" checkbox section_field" id="helpdesk_ticket_custom_field_cf_clinical_investigation_device_770455_35000329731" name="helpdesk_ticket[custom_field][cf_clinical_investigation_device_770455]" type="checkbox" value="1" /> This is an investigational device that is part of a clinical study? (check if yes) </label> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_serial_number_770455-label " for="helpdesk_ticket_cf_serial_number_770455">Serial Number</label> <div class="controls "> <input class=" text section_field span12" id="helpdesk_ticket_custom_field_cf_serial_number_770455" name="helpdesk_ticket[custom_field][cf_serial_number_770455]" size="30" type="text" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_udi_770455-label " for="helpdesk_ticket_cf_udi_770455">UDI</label> <div class="controls "> <input class=" text section_field span12" id="helpdesk_ticket_custom_field_cf_udi_770455" name="helpdesk_ticket[custom_field][cf_udi_770455]" size="30" type="text" /> </div> </div>
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